Journal Feed Weekly Wrap-Up

We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter. 

Originally published at JournalFeed, a site that provides daily or weekly literature updates. 

Follow Dr. Clay Smith at @spoonfedEM, and sign up for email updates here.

#1: Outcome of Pediatric Bradycardia- Poor Perfusion vs PEA

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Bradycardia with poor perfusion is associated with better survival with favorable neurologic outcome than pulseless cardiac arrest in critically ill children receiving CPR.

Why does this matter?

Bradycardia is common in children, and often progresses to pulseless arrest. Even with a pulse present, CPR can give you better hemodynamics!

Slow Code | Slow? CODE!

This was a prospective multi-center observational cohort study of CPR events in the ICUs of 11 children’s hospitals from 2013 – 2016. The authors compared children with pre-existing arterial lines capturing CPR events for pulseless cardiac arrest and bradycardia with poor perfusion, hypothesizing that the latter would be associated with better outcome (spoiler alert: it was).  They analyzed data from 164 patients. This was an ICU-centric study, but there are several EM-applicable pearls!

Population: Kids <1 year old were more likely to present with bradycardia. The majority had pre-existing respiratory insufficiency (82% invasive mechanical ventilation) and/or hypotension. 60% of the patients had congenital heart disease. Those who got CPR for bradycardia were more likely to have a respiratory etiology.

  • Pearl #1: Bradycardia is common in younger kids! (but you knew that)

  • Pearl #2: Anticipate bradycardia with poor perfusion when you see a kid with respiratory disease.

The CPR events themselves did not differ between groups – 90% of patients survived the events overall, 68% of them via ROSC and 22% via ECPR.

Events lasted 8 minutes on average, and patients got 3 doses of epinephrine on average. About half of patients got sodium bicarbonate and calcium, respectively.

About half presented in bradycardia, got CPR, and lost pulses. They had lower diastolic blood pressure during CPR. Interestingly, while those who became pulseless during CPR had lower rates of ROSC, they did not show differences in rates of survival with good neurologic outcome compared with those who were never pulseless!

  • Pearl #4: Don’t abandon hope if your bradycardic pediatric patient develops PEA during CPR!

Patients with initial bradycardia and poor perfusion were more likely than pulseless patients to survive to hospital discharge (54% vs. 37%, p = 0.039) and to survive with favorable neurologic outcome (50% vs. 32%, p = 0.026). The following pearl is a logical stretch that can’t technically be made with an observational study, but with that caveat:

  • Pearl #5: Starting CPR for bradycardia with poor perfusion BEFORE the loss of pulse is a really good idea!  It’s also part of PALS, notably the bradycardia algorithm.

Survival and Hemodynamics During Pediatric Cardiopulmonary Resuscitation for Bradycardia and Poor Perfusion Versus Pulseless Cardiac Arrest. Crit Care Med. 2020 Jun;48(6):881-889. doi: 10.1097/CCM.0000000000004308.

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#2:  Brain Clot Score – Cerebral Venous Thrombosis Rule

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A new scoring system was developed for cerebral venous thrombosis (CVT). It is not ready for implementation until externally validated, but it was encouraging that none with a score of 0-2 and D-dimer <500 had CVT.

Why does this matter?
Dural venous sinus thrombosis or CVT is a difficult diagnosis to make. It may result after trauma or may be spontaneous. It is in the differential diagnosis of thunderclap headache but may have more gradual onset as well. It is just tricky. Imaging with CTV or MRV can get the diagnosis, but you have to think of it to diagnose it.

Brain clot score
This was a prospective study to determine a workable scoring system to diagnose CVT and to see what D-dimer threshold would be best from a lab standpoint. The prevalence of disease was 25.8% (94/359). Using multiple logistic regression, they made the following scoring system, 0-14 points (or 0-17 points if D-dimer was added):

  • seizure(s) at presentation (4 points)

  • known thrombophilia (4 points)

  • oral contraception (2 points)

  • duration of symptoms >6 days (2 points)

  • worst headache ever (1 point)

  • focal neurological deficit at presentation (1 point).

  • *alternately may consider D-dimer ≥500 (3 points)

No patient with CVT had a D-dimer <500 microgram/L. PPV was 100% with a score 9-17 (when a D-dimer ≥500 was worth 3 points). No patient with a score of 0-2 and D-dimer <500 had CVT. This score needs external validation before we rely on it. But look at those score components; those are the items we need to be assessing in our headache patients. I need to think about OCPs and thrombophilia. This helps me weigh whether I should order a CTV or MRV, even if I may not rely on the actual score yet in practice. I think it is helpful as an objective way to guide imaging choices.

Prediction of Cerebral Venous Thrombosis with a new clinical score and D-dimer levels. Neurology. 2020 Jun 23:10.1212/WNL.0000000000009998. doi: 10.1212/WNL.0000000000009998. Online ahead of print.

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For more on CVT, see this emDocs post.

#3: Ketamine vs Etomidate – Hypotension At Induction

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Ketamine was associated with a greater risk of peri-intubation hypotension than etomidate.

Why does this matter?
Ketamine has magical powers causing catecholamine release and usually raises heart rate and BP. However, it may cause myocardial depression. Etomidate is also known to be hemodynamically neutral yet is known to cause adrenal suppression for about 24 hours, which is of questionable clinical significance. What if ketamine was compared with etomidate in regard to hypotension?

Ketamine raises BP, right?
This was a retrospective look at National Emergency Airway Registry (NEAR) data comparing the hemodynamic effects in non-hypertensive patients over 14 years old in 738 intubations with ketamine and 6,068 with etomidate. To my surprise, ketamine was more likely to cause peri-intubation hypotension (defined as <100 systolic) than etomidate; 18.3% vs 12.4%, respectively (5.9% difference, 95%CI 2.9 to 8.8%). More patients needed intervention for peri-intubation hypotension with ketamine as well. Patients receiving ketamine were more likely to have a difficult airway and have video over direct laryngoscopy. Yet even with logistic regression and adjustment, the increased risk of peri-intubation hypotension remained. Low-dose ketamine (≤1mg/kg) was not found to be associated with hypotension. Results could have been confounded if doctors chose ketamine for use in sicker, more unstable patients.

Three take home points the authors emphasized:

  1. Ketamine may not be superior for hemodynamics in unstable patients.

  2. Optimize pre-induction resuscitation no matter what drug you choose.

  3. Use lower dose ketamine in very unstable patients.

Ketamine versus Etomidate and Peri-Intubation Hypotension: A National Emergency Airway Registry Study. Acad Emerg Med. 2020 Jun 26. doi: 10.1111/acem.14063. Online ahead of print.

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#4: And Thus Ends the GI Cocktail

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Antacid monotherapy is as effective, if not more effective, than GI cocktails with lidocaine, is more palatable, and has fewer side effects.

Why does this matter?
In prior studies, it is questionable whether additives like lidocaine or donnatal are…well additive to effectiveness beyond a simple antacid.

Feel the burn…or not
This was a single-blinded RCT with 89 patients with reflux-type pain who were randomized to antacid monotherapy (aluminum hydroxide/magnesium trisilicate/magnesium hydroxide), antacid/lidocaine 2% solution, or antacid/lidocaine 2% viscous gel. For the primary outcome of pain reduction on visual analog scale (VAS) at 30 minutes, both antacid and antacid+solution gave clinically significant pain reduction. VAS reduction in pain was 20 (antacid), 17 (antacid+solution), and 9 (antacid+viscous). The viscous group did not meet >13mm VAS decrease considered clinically important. There was no statistical difference between the three groups. Antacid alone was (non-significantly) more effective than all the others. It was also the most palatable. Both lidocaine preparations caused oral numbness. All three provided pain relief >13mm at 60 minutes. The take-home point is that a plain antacid is as effective, if not more effective, that GI cocktails with lidocaine, is more palatable, and has fewer side effects.

Antacid monotherapy is more effective in relieving epigastric pain than in combination with lidocaine. A randomized double-blind clinical trial. Acad Emerg Med. 2020 Jun 29. doi: 10.1111/acem.14069. Online ahead of print.

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